Cystitis is an inflammation of the bladder. Most cystitis is from bacterial infections involving the bladder and less commonly may be due to other infectious diseases, including yeast infections, viral infections, or the result of other causes such as chemical irritants of the bladder, or for unknown reasons (interstitial cystitis). Bladder infection (infectious cystitis) is a type of urinary tract infection (UTI). Other forms of urinary tract infection include pyelonephritis (kidney infection/inflammation), urethritis (infection/inflammation of the urethra), and prostatitis (inflammation/infection of the prostate gland). This review will specifically address infectious cystitis.
The urine in the bladder usually is free of bacteria (sterile). However, bacteria may be present in the bladder but not cause inflammation or symptoms of an infection. This is asymptomatic bacteriuria, not cystitis. Asymptomatic bacteriuria is bacteria in the urine that does not cause symptoms. It is crucial to differentiate asymptomatic bacteriuria from cystitis, to prevent overuse of antibiotics. Most people with asymptomatic bacteriuria do not require antibiotics. The guidelines for the Infectious Disease Society of America recommend only treating asymptomatic bacteriuria in pregnant women or immediately before urologic procedures.
Cystitis can be complicated or uncomplicated. Uncomplicated cystitis is a bladder infection in a healthy person with a structurally and functionally normal urinary tract. A complicated bladder infection is one that is associated with factors that increase the chance of developing a bacterial infection and decrease antibiotic therapy’s likelihood of being effective. Such abnormalities include obstruction from stones, congenital blockages, urethral strictures, and prostate enlargement.
Symptoms of a bladder infection are similar to those of any lower urinary tract infection (UTI). These symptoms are identical in men, women, and children. The main signs of bladder infection are:
• or burning when trying to urinate.
There may be a sense of needing to frequently urinate (urinary frequency) or having to urinate urgently (urinary urgency). Passing only a small amount of urine even though you feel the need to urinate is another common symptom. A cloudy appearance to the urine can be present if there is a bacterial infection that produces pus in the urine. The urine also may be red due to bleeding. Alternatively, the urine may not be changed in appearance, but red blood cells, bacteria, or white blood cells may be detected on microscopic examination of the urine.
All urinary tract infections are the result of interactions between the infecting organism (bacteria, yeast, virus), the number of microorganisms present in the bladder, and the body’s ability to fight off the plant (host defense mechanisms).
The most common way bacteria gain access to the urinary system from outside is through the urethra (the tube that allows urine to pass from the bladder to outside of the body).
• The most common source of bacteria that cause UTIs is from the stool.
• In women, the bacteria from the stool travel first to the vagina and then enter the urethra.
• Sometimes bacteria may enter the bladder via the urethra from nearby skin.
• In general, women are more susceptible to bladder infections due to their shorter length of the urethra.
• In the first year of life, boys are at higher risk of UTIs, but after that, girls have a higher risk of persists in adulthood.
• Increasing age is a risk factor for UTIs.
In terms of specific bacteria, E. coli (Escherichia coli) is by far the most common organism responsible for bladder infection or cystitis. Staphylococcal (staph) organisms (from the skin) and other gut bacteria (Proteus, Klebsiella, Enterococcus) are other bacteria that can cause cystitis and other forms of urinary infections. The type of organism causing the disease can vary with the individual’s age. For example, Staphylococcus saprophyticus, skin bacteria, causes approximately 10% of symptomatic bladder infections in young, sexually active women, whereas it rarely causes bladder infections in males and elderly individuals.
Rarely, fungi can cause bladder infections. Candida is the most common fungus to cause a bladder infection. Candida infections of the bladder and urinary tract are much less common than bacterial infections. Bladder infections from Candida can occur in patients whose immune system is weakened, individuals who have been treated with powerful antibiotics for other infections, and individuals who have had indwelling urinary catheters.
Viruses can rarely cause bladder infections. Viral cystitis can occur in individuals after bone marrow transplantation and in other individuals with a weakened immune system (immunocompromised individuals). Adenovirus can cause bladder infections, and BK is another virus that can cause bladder infections in individuals who have undergone bone marrow transplantation.
It is vital to modify risk factors, when possible, to decrease the risk of recurrent urinary tract infections.
Female gender is one of the main risk factors for bladder infection. Women are at increased risk for bladder infections for several reasons, including the following:
1. Women have a shorter urethra than men, which allows bacteria to gain much easier access to the bladder than in men.
2. Sexual activity can increase the risk of urinary tract infections. Sexually active women tend to have more urinary tract infections than women who are not sexually active.
3. The type of birth control a woman uses can affect the risk of developing urinary tract infections. Women who use diaphragms for birth control may have a higher risk of urinary tract infections, and women who use spermicidal agents.
4. Menopausal women are at higher risk of developing urinary tract infections. Decreased estrogen levels cause changes in the urinary tract, making it more susceptible to bacteria.
Bacteria in the bladder is one of the most common infectious issues that occur in pregnancy. The risk of having bacteria in the urine increases with lower socioeconomic status, history of multiple children, and sickle cell trait. Pregnant women are less likely to clear the bacteria in the bladder compared to nonpregnant women and are more likely to develop symptoms. Also, pregnant women have a higher risk of a bladder infection progressing to a kidney infection (pyelonephritis).
Other risk factors include the following:
1. Urinary tract abnormalities such as obstruction to the flow of urine at any level, vesicoureteral reflux (a structural abnormality that allows urine to go backward from the bladder to the kidneys), and neurologic conditions that affect bladder function
2. In men with prostate enlargement, a bladder infection is more common than in the general male population. Prostate enlargement can lead to obstruction of the normal flow of urine out of the bladder and into the urethra. Residual urine can then become infected. The higher bladder pressure needed to push urine past the enlarged prostate causes decreased blood flow to the bladder, making it more susceptible to bacteria.
3. Urinary catheters (Foley catheters) are another potential risk for bladder infection. People typically use these urinary catheters in settings where an individual may not be able to urinate naturally. Urinary catheters simply provide a physical vehicle to transport bacteria into the bladder and the urinary system directly. Foley catheters are commonly used in patients with severe illness, limited mobility, urinary incontinence (inability to hold their urine), bladder obstruction and urinary retention (prostate enlargement, urethral scarring, prostate cancer), bladder trauma, bladder cancer, bladder dysfunction due to neurologic conditions, or who are unable to get out of bed.
4. Bladder infection is more commonly seen in patients with neurologic conditions that may affect bladder function, such as multiple sclerosis (MS), stroke, and other nervous system diseases than in public. In these and other similar neurologic disorders, bladder function may be impaired due to the bladder’s abnormal nervous system control (neurogenic bladder). As a result, a person may retain urine in the bladder after voiding. Urinary retention can be a cause of bladder infection. Furthermore, if urinary retention becomes more serious, causing pain and kidney dysfunction, Foley catheters may become necessary to empty the bladder and relieve the bladder pressure caused by excessive urine retention. A catheter, in turn, can substantially increase the risk of bladder infection.
5. In addition to the Foley catheter, any instrumentation of the urinary tract or nearby structures can lead to cystitis. Medical procedures (cystoscopy, bladder biopsy, prostate procedures), vaginal pessary, and IUD (intrauterine device) placement for birth control can pose an increased risk of developing a bladder infection.
6. In children and toddlers, the risk for bladder infection may be higher in females, uncircumcised males, those with structural abnormalities of the urinary tract, and Caucasians (four times higher than in African Americans).
7. Older adults are also at higher risk of suffering bladder infections, as are individuals who take medications that weaken the immune defense system.
Because cystitis is more common in women, most signs and symptoms listed below pertain to cystitis in women unless otherwise indicated.
General symptoms of a bladder infection may include the following:
• Dysuria (painful urination)
• Urinary frequency
• Urinary urgency (sudden, compelling urge to urinate)
• Hesitancy to void urine
• Bladder pain (pain in the lower abdomen around the pubic bone and pelvic area)
• Incomplete voiding of urine (leaving urine in the bladder after urinating)
• Urinary incontinence (involuntary loss of urine), which may be associated with urgency
Fevers, chills, nausea, vomiting, and inadequate oral intake rarely occur with a bladder infection, although they are more common upper urinary tract infections, such as pyelonephritis (kidney infection).
Some common signs of bladder infection are:
• lower abdominal tenderness;
• blood in the urine (hematuria);
• less commonly, tenderness on the sides of the back (flanks);
• foul-smelling urine; and
• in elderly patients, lethargy or confusion may be the only signs.
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